Healthcare Provider Details

I. General information

NPI: 1811469414
Provider Name (Legal Business Name): MORENIKE ESTHER AGBOOLA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 RACE RD STE 403
ROSEDALE MD
21237-2386
US

IV. Provider business mailing address

8126 OLD PHILA RD
BALTIMORE MD
21237-2840
US

V. Phone/Fax

Practice location:
  • Phone: 480-878-7806
  • Fax: 443-732-0054
Mailing address:
  • Phone: 443-418-6927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR184584
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: